APKIM Youth Counselling Registration Form

APKIM Youth Counselling Registration

All information provided is strictly confidential
Email
example@example.com
Name of Client

First NameLast Name
Gender
Age
Unfortunately, the Free Youth Counselling is only applicable for those below 26 years old. Should you still be interested in taking up counselling sessions with APKIM at $160/hour, you may register at tinyurl.com/apkimptecounselling
Religion
Unfortunately, the Free Youth Counselling is only applicable for Muslim youths below 26 years old. Should you still be interested in taking up counselling sessions with APKIM at $160/hour, you may register at tinyurl.com/apkimptecounselling
Phone Number
Employment Status
If you are currently a Student, please state your Name of School
Gross monthly income

Please select your preferred appointment date. An email will be given to confirm which appointment is available or explore other alternative slots, hence do check and respond to the email.

Appointments will be subject to counsellors availability. We are not open on weekends and public holidays.
Counselling Session
Please select an alternative appointment date

Please provide an alternative slot of at least 2 weeks from now. Our office with update on the availability of the slot you have requested.
Alternative Date of Counselling Session
Is the session Online or In-Person?

Details of Unplanned Pregnancy
Details of Relevant People involved( Name, Age, Relationship & any other relevant information)
Key Issues and concerns you would like to highlight to the Counsellor

Payment

Deposit is $20 per hour. Please make payment via PAYNOW by scanning the QR code, or inputting APKIM Resources UEN 49696000L001.
Please upload a screenshot of the receipt

Cancelof
Please verify that you are human
Should be Empty:

APKIM Youth Counselling Registration